Name *

First Name

Last Name

Was there an act of violence against you? *

An act of violence can be physical, psychological or emotional. It can result in death or injury like physical harm, mental illness or disorder from the event or an increase in mental illness or disorder. NOT INCLUDED: damage/loss of property; breaching an Intervention Order (unless injury caused); home invasion (unless victim was present)

YES

NO

When did the act of violence occur? *

MM

DD

YYYY

Have you made an application for the act of violence before? *

If YES, we can assist in furthering your claim. If NO, we can assist in lodging your claim.

YES

NO

Did you make a police statement when the act of violence was reported?

If YES, please bring a copy of this statement to your consultation and/or email in advance to reception@hartleyslawyers.com.au with "LASTNAME FIRST INTERVIEW" as your email subject.

YES

NO